Bone Bridge Research Articles

Assessment of Extra-Cortical Bone Bridge Interface in Cemented Mega Endoprosthesis for Limb Salvage Surgery.

Introduction:Mega endoprosthesis replacement for resection of primary malignant bone tumour requires immediate and long-term stability, particularly in the young and active patient. Extracortical bone bridge interface (EBBI) is a technique whereby autograft is wrapped around the interface junction of bone and porous-coated implant to induce and enhance bone formation for biological incorporation. This procedure increases the mean torsional stiffness and the mean maximum torque, which eventually improves the implant's long-term survival.Material and methods:The extracortical bone bridge interface's radiological parameter was evaluated at the prosthesis bone junction two years after surgery utilising a picture archiving and communication system (PACS). The radiograph's anteroposterior and lateral view was analysed for both thickness and length in all four cortices. The analysis was done in SPSS Version 24 using One-Way ANOVA and independent T-Test. Results were presented as mean and standard deviation and considered significant when the p-value was < 0.05.Results:The mean average thickness was 2.2293mm (SD 1.829), and the mean average length was 31.95% (SD 24.55). We observed that the thickness and length of EBBI were superior in the young patient or patients with giant cell tumour that did not receive chemotherapy, compared to patients treated for osteosarcoma. The distal femur also had better EBBI compared to the proximal tibia. However, the final multivariable statistical analysis showed no significant difference in all variables. EBBI thickness was significantly and positively correlated with EBBI Length (p<0.001). We conclude that, for each 1mm increase in EBBI thickness, the length will increase by 0.06% on average. About 17.2% of patients out of the 29 showed no radiological evidence of EBBI.Conclusion:From our study, there were no factors that significantly contributed to the formation and incorporation of EBBI

Lateral Meniscal Allograft Transplant: Dovetail Bone Bridge Preparation

Meniscal tears are among the most common knee injuries encountered by an orthopaedic surgeon. Once treated with total meniscectomy, meniscal preservation is now the standard of care. Not all meniscal tears are repairable, and meniscal allograft transplantation has become an integral part of the preservation algorithm. This procedure is often recommended in a young active patient with healthy articular cartilage who has undergone a previous subtotal or total meniscectomy. There are many surgical methods for meniscal allograft transplantation, and the bone bridge technique has shown good improvement in outcome scores and good long-term survival. We describe our preferred technique for preparation of the dovetail bone bridge meniscal allograft for lateral meniscal allograft transplantation.

Simple Cost-Effective Reinsertion of Avulsed Medial Patellofemoral Ligament in Acute Patellar Dislocation

The medial patellofemoral ligament (MPFL) is the main restraining force against lateral patellar displacement in the first 20° of flexion and is disrupted after patellar subluxation or dislocation. Management of acute patellar dislocations is controversial, and many clinicians opt for conservative treatment in the acute phase. However, a traumatic rupture of the MPFL warrants surgical attention. Several considerations must be made by surgeons attempting reinsertion of the MPFL, including the choice of implant and timing of surgery, to restore the anatomy and biomechanics of the patellofemoral joint. Our aim is to achieve robust reinsertion of the MPFL restoring the anatomy and biomechanics of the patellofemoral joint using a simple, reproducible, and economical technique. We present MPFL reinsertion to the medial border of the patella in an acute patellar dislocation with a braided No. 2 ultrahigh-molecular-weight polyethylene suture (No. 2 Ultrabraid; Smith & Nephew, Memphis, TN) that is passed through 3 transverse parallel tunnels and tied over a bone bridge on the lateral border of the patella. This technique is simple with no implanted hardware, does not have the risk of donor-site morbidity of MPFL reconstruction, and can be performed in skeletally immature patients without growth plate concerns.

The Significance of Extra-Cage Bridging Bone via Radiographic Lumbar Interbody Fusion Criterion.

Prospective observational study. We aimed to analysis the distributional patterns of the intra- and extra-cage bridging bone (InCBB and ExCBB) and the significance of ExCBB using suggested lumbar interbody fusion criterion. This study included the patients with planned single-level transforaminal lumbar interbody fusion. We divided bridging bone into InCBB (in void of right or left cage) and ExCBB (outside of cages; anterior, posterior, intermediate, right, or left) and graded bridging scores from 0 to 2 on postoperative 1-year computed tomography. The fusion was defined as at least having one or more graded 2 and the evaluation were conducted twice by 2 raters. Sixty-five patients were enrolled. All values of intra- and inter-rater reliability in left InCBB, anterior, and posterior ExCBB showed good agreements (≥0.75). Both InCBBs showed similar mean bridging scores (Rt:1.43 vs Lt:1.48), and in ExCBBs, the anterior was the highest (1.43), followed by the posterior (1.14); the right and left were the lowest (0.49 and 0.52 respectively). In subjects determined as fusion (85.4%), complete bridging was observed more in ExCBB (88.8%) than in InCBB (69.9%). Given the higher bridging scores in both InCBBs and Ant. ExCBB, bone grafting is important promoting factor to increase the interbody bridging bone regardless of outside or in void of cages. Based on our suggested criterion, ExCBB has a greater proportion compared to InCBBs for determining the fusion and extra-cage bone grafting should be considered as important procedures for interbody fusion.

Bacillus Cereus Osteomyelitis in an Athlete: Case Report and Review of the Literature

Bacillus cereus is an aerobic Gram-positive, spore-forming rod, widely distributed in the environment. Although, most commonly known to cause gastrointestinal infections, B. cereus can also cause osteomyelitis and other deep-seated infections. Here we describe the case of an athlete who presented with B. cereus osteomyelitis following surgery for closed displaced mid shaft fracture of tibia and fibula sustained during a football match. The patient had internal reduction and fixation of the fracture; Cephazolin was given as prophylaxis. 9 weeks later he developed osteomyelitis, B. cereus was isolated from specimens collected during surgery which was treated with Teicoplanin and Ciprofloxacin. After initial improvement X-ray showed progressive posterior bone bridge at the site of the fracture and no obvious evolution of the distal aspect of the tibia in comparison with the previous radiography. The patient was then transferred to a referral hospital where he had another surgery to drain the pus and remove the intramedullary prosthesis. At this stage Clostridium aerotolerans and Propionibacterium acne were isolated from the tissues, treated successfully with metronidazole. Bacillus cereus osteomyelitis should be considered in the differential diagnosis for infection following limb trauma. It is prudent to use for prophylaxis Vancomycin or Teicoplanin in such situation instead of Cephazolin to which B. cereus is usually resistant due to the production of beta lactamases.

Comparison of Extragraft Bone Formation after Anterior Cervical Discectomy and Fusion Using Simultaneous and Sequential Algorithms

Extragraft bone formation is crucial for obtaining a successful outcome after spinal fusion surgery. However, the cause of bone formation is not well investigated. In this study, it was hypothesised that extragraft bone formation is generated by mechanical stimuli. A preoperative plan for anterior cervical discectomy and fusion was applied to the finite element model of the C5–C6 motion segment. Extragraft bone formations posterior to the interbody cage were simulated using simultaneous and sequential algorithms. While the simultaneous algorithm predicted the formation of extragraft bone bridging under flexion and extension, the bridge was generated only under extension with the sequential algorithm. This was caused by an ill-defined design space in cases where the simultaneous algorithm was used. Our results using the sequential algorithm show how the progress of extragraft bone formation affects spine mechanics, and our results support the hypothesis that a mechanical stimulus is a major factor influencing extragraft bone formation.

Functional repair of critically sized femoral defects treated with bioinspired titanium gyroid-sheet scaffolds

Despite the innate ability for bone to remodel and repair, its regeneration has a limit. In these cases of critically sized bone defects (CSBD), the bone deficit must be repaired using reconstructive techniques that support immediate load bearing and encourage bone bridging across the defect. High-strength porous titanium implants offer a solution for treatment of CSBD in which the scaffold can support physiological loads, provide a matrix to guide ingrowth, and carry graft materials and/or biologics. Fabrication of titanium meta-materials via additive manufacturing (AM) has unlocked the potential to modulate mechanical and biological performance to achieve a combination of properties previously unachievable. Meta-material scaffolds with topology based on triply periodic minimal surfaces (TPMS) have gained increasing interest for use in biomedical applications due to their bioinspired nature. Despite enthusiasm for TPMS-based titanium scaffolds due to their high strength to stiffness ratio, high permeability, and curvature similar to trabecular bone, there is little preclinical evidence to support their in vivo response in bone. The present study sought to evaluate the performance of gyroid-sheet titanium scaffolds produced via AM to repair a critically size femoral cortical bone defect in rats. Empty gyroid-sheet scaffolds were shown to repair segmental defects with up to 38% of torsional strength and 54% torsional stiffness of the intact femur (control) at 12-weeks. Gyroid-sheet scaffolds carrying recombinant bone morphogenic protein-2 demonstrated bridging bone growth across the length of the defect, with torsional strength and stiffness superior to that of the intact controls.

Evaluation of the Effectiveness of Using Platelet Rich Fibrin (PRF) With Bone Graft in the Reconstruction of Alveolar Cleft, A Prospective Study.

The aim of this prospective study is to investigate and evaluate the quality and quantity of the bone graft that mixed with PRF when used in reconstruction of alveolar cleft in terms of bone density and resorption rate of the bone graft. Sixteen patients with unilateral alveolar clefts were treated. The control group received bone grafts without PRF, while the remaining patients comprised the PRF group and received grafts with PRF. Postoperative bone graft density and rate of bone resorption were assessed by CBCT at 1 month and 6 months after surgery. Satisfactory bone bridging formation was observed in all patients and the mean of bone resorption in PRF group within 6 months after surgery lower than control group. The bone density of the PRF group was lower than that of the control group at 1st month, which later after 6 months increased to be more than the control group. Platelet rich fibrin that mixed with autogenous bone graft was significantly reduce postoperative bone resorption. PRF may provide a higher bone density in the long postoperative course.

Ibudilast Mitigates Delayed Bone Healing Caused by Lipopolysaccharide by Altering Osteoblast and Osteoclast Activity.

Bacterial infection in orthopedic surgery is challenging because cell wall components released after bactericidal treatment can alter osteoblast and osteoclast activity and impair fracture stability. However, the precise effects and mechanisms whereby cell wall components impair bone healing are unclear. In this study, we characterized the effects of lipopolysaccharide (LPS) on bone healing and osteoclast and osteoblast activity in vitro and in vivo and evaluated the effects of ibudilast, an antagonist of toll-like receptor 4 (TLR4), on LPS-induced changes. In particular, micro-computed tomography was used to reconstruct femoral morphology and analyze callus bone content in a femoral defect mouse model. In the sham-treated group, significant bone bridge and cancellous bone formation were observed after surgery, however, LPS treatment delayed bone bridge and cancellous bone formation. LPS inhibited osteogenic factor-induced MC3T3-E1 cell differentiation, alkaline phosphatase (ALP) levels, calcium deposition, and osteopontin secretion and increased the activity of osteoclast-associated molecules, including cathepsin K and tartrate-resistant acid phosphatase in vitro. Finally, ibudilast blocked the LPS-induced inhibition of osteoblast activation and activation of osteoclast in vitro and attenuated LPS-induced delayed callus bone formation in vivo. Our results provide a basis for the development of a novel strategy for the treatment of bone infection.

Arthroscopic Suture Fixation of Tibial Eminence Fracture

Background: Tibial eminence fractures account for up to 5% of knee injuries with an effusion in the pediatric population. Displaced fractures require reduction and operative fixation via arthroscopic or open techniques. Indications: Arthroscopic suture fixation and screw fixation are 2 of the most commonly described techniques for tibial eminence fracture treatment. We describe our preferred technique of arthroscopic suture fixation given the versatility of this technique and decreased risks of hardware irritation or impingement, need for reoperation, and minimal risk of physeal damage. Technique Description: The arthroscopic suture fixation technique uses a standard anteromedial and anterolateral portal. After the fracture bed and hematoma are debrided and any interposing structures (ie, meniscus) are removed from the fracture site, 2 nonabsorbable sutures are passed through the substance of the anterior cruciate ligament (ACL). Using an ACL guide, 2 separate transtibial tunnels are drilled with a bone bridge in between—one at the anterolateral aspect of the fracture base and one at the anteromedial aspect. One limb from each suture is pulled out from each of the bone tunnels. The fragment is then reduced, and the sutures are tensioned and fixated using knotless suture anchors. Results: Overall prognosis following tibial eminence fracture fixation is favorable with more than 80% of patients returning to prior level of activity. Arthrofibrosis may occur in up to 25% of patients. Although some residual laxity may remain, there is a high return to sport and no difference in rate of subsequent ACL injury or surgery compared with a match cohort of pediatric ACL reconstructions. Discussion: Arthroscopic suture fixation of displaced tibial eminence fractures is a reliable technique with high return to sport and low risk of reoperation. Arthrofibrosis is common; thus, early, controlled knee range of motion following surgery is critical.

Three-dimensional printed poly (L-lactide) and hydroxyapatite composite for reconstruction of critical bone defect in rabbits.

ABSTRACTPurposeTo use a 3D printed poly (L-lactide) acid (PLLA) and hydroxyapatite (HA) composite as a bone substitute for reconstruction of a critical bone defect in the radius of rabbits.MethodsA 1.5 cm ostectomy was performed in the radial diaphysis of 60 New Zealand white rabbits. The rabbits were divided into three groups according to surgical treatment of the bone defect (group I – control, group II – bone graft, group III – 3D PLLA). Each group was divided into four subgroups with different radiographic and histopathologic evaluation times (T1 – 15 days, T2 – 30 days, T3 – 60 days, T4 – 90 days).ResultsThe implant group had greater clinically lameness (p = 0.02), edema (p = 0.007), pain (p = 0.04) and more complications at the surgical site (p = 0.03). Histologically, this group showed greater congestion (p = 0.04), hemorrhage (p = 0.04) and inflammation. Osteogenesis was microscopically similar between days (p = 0.54) and treatments (p = 0.17), even though radiographically, more effective bone healing occurred in the graft group (II), with more callus and bone bridge formation.ConclusionsThe customization of a 3D PLLA/HA scaffold was successful. However, in animals receiving the polymer-ceramic composite less bone callus and bone bridge was formed compared to the graft group.

A prospective study of surgical management of diaphyseal shaft fracture of bones of forearm in adults with limited contact dynamic compression plate

Fracture of forearm bone are one of the most common injuries seen in day to day practice. The forearm, in combination with the proximal and distal radioulnar joints, allows pronation and supination movements that are important in the usual activities of daily living. The forearm serves an important role in upper extremity function. Decisive management is required after fractures of the shafts of the radius and ulna if function is to be restored. The Limited Contact Dynamic Compression Plate, was developed by Perren S. M. et to release the new concept of biological internal fixation. Grooves on the undersurface of the LC-DCP improved blood circulation. There is decreased damage to contact between plate and bone. It also allows for a small bone bridge beneath the plate at the most critical area, which is otherwise weak due to a stress concentration effect. This study is undertaken to assess the results of diaphyseal fractures of Bones of Forearm using LCDCP to study the advantages and its complications.Materials and Methods: Patients admitted to Cg Hospital and Bapuji Hospital between 2019 July to 2020 September were taken into the study after taking informed consent.Results: This study consists of 30 cases of fracture Both Bone Forearm Fractures. All cases were openly reduced and internally fixed with 3.5 mm LCDCP. Fracture was common in second and third decade. In our study, male preponderance was found with 73.3% males and 26.7% female patients. Side affected 24(80%) Left side and 6 patients (20%) right side. Mode of injury in the present study was RTA (33.3%) and fall (66.6%). An average time for union was around 5 months. Results were evaluated by Andersons scoring system. In present study, we had 24 patients (80%) with excellent results, 5 case (16.6%) as satisfactory and 1 case (2%) as unsatisfactory. No case needed refixation. In the present study there was 3 case (10%) of superficial infection, 1 case (3.3%) of Posterior Interosseous Nerve injury. Conclusion: LC-DCP can be considered the best mode of treatment for closed diaphyseal fractures of both bones forearm.

Guided bone regeneration with osteoconductive grafts and PDGF: A tissue engineering option for segmental bone defect reconstruction.

Regeneration and reconstruction of segmental bone defects (SBD) is a clinical challenge in maxillofacial surgery and orthopedics. The present study evaluated efficacy of guided bone-regeneration (GBR) of rat femoral SBD using osteoconductive equine-bone (EB) and beta-tricalcium phosphate (beta-TCP) grafts, either with or without platelet-derived growth-factor (PDGF). Following ethical-approval, 50 male Wistar-Albino rats (aged ~12-15 months and weighing ~450-500 g) were included. A 5 mm femoral critical-size SBD was created and animals were divided into five groups depending on the graft material used for GBR (EB, EB + PDGF, Autograft, beta-TCP, beta-TCP + PDGF; n = 10/group). Following 12-weeks of healing, animals were sacrificed and femur specimens were analyzed through qualitative histology and quantitative histomorphometry. There was new bone bridging femoral SBD in all groups and qualitatively, better bone formation was seen in autograft and EB + PDGF groups. Histomorphometric bone-area (BA %) was significantly high in autograft group, followed by EB + PDGF, beta-TCP + PDGF, EB, and beta-TCP groups. Addition of PDGF to EB and beta-TCP during GBR resulted in significantly higher BA%. After 12-weeks of healing, EB + PDGF for GBR of rat femoral segmental defects resulted in new bone formation similar to that of autograft. Based on this study, GBR with EB and adjunct PDGF could be a potential clinical alternative for reconstruction and regeneration of segmental bone defects.

Regeneration in Experimental Alveolar Bone Defect Using Human Umbilical Cord Mesenchymal Stem Cells

Cleft lip and palate is a congenital disorder including cleft lip, and/or cleft palate, and/or alveolar cleft, with high incidence.The alveolar cleft causes morphological and functional abnormalities. To obtain bone bridge formation and continuous structure between alveolar clefts, surgical interventions are performed from infancy to childhood. However, desirable bone bridge formation is not obtained in many cases. Regenerative medicine using mesenchymal stem cells (MSCs) is expected to be a useful strategy to obtain sufficient bone bridge formation between alveolar clefts. In this study, we examined the effect of human umbilical cord-derived MSCs by transplantation into a rat experimental alveolar cleft model. Human umbilical cords were digested enzymatically and the isolated cells were collected (UC-EZ cells). Next, CD146-positive cells were enriched from UC-EZ cells by magnetic-activated cell sorting (UC-MACS cells). UC-EZ and UC-MACS cells showed MSC gene/protein expression, in vitro. Both cells had multipotency and could differentiate to osteogenic, chondrogenic, and adipogenic lineages under the differentiation-inducing media. However, UC-EZ cells lacked Sox2 expression and showed the lower ratio of MSCs than UC-MACS cells. Thus, UC-MACS cells were transplanted with hydroxyapatite and collagen (HA + Col) into alveolar cleft model to evaluate bone formation in vivo. The results of micro computed tomography and histological staining showed that UC-MACS cells with HA + Col induced more abundant bone formation between the experimental alveolar clefts than HA + Col implantation only. Cells immunopositive for osteopontin were accumulated along the bone surface and some of them were embedded in the bone. Cells immunopositive for human-specific mitochondria were aligned along the newly formed bone surface and in the new bone, suggesting that UC-MACS cells contributed to the bone bridge formation between alveolar clefts. These findings indicate that human umbilical cords are reliable bioresource and UC-MACS cells are useful for the alveolar cleft regeneration.

Biomechanical assessment of docking ulnar collateral ligament reconstruction after failed ulnar collateral ligament repair with suture augmentation

Ulnar collateral ligament (UCL) repair with single-strand suture augmentation has been introduced as a viable surgical option for throwers with acute UCL tears. For the original single-strand suture augmentation construct, revision UCL reconstructions can be challenging owing to the bone loss at the site of anchor insertion in the center of the sublime tubercle. This biomechanical study assessed a small-diameter (1.5-mm) ulnar bone tunnel technique for double-strand suture-augmented UCL repair that may be more easily converted to salvage UCL reconstruction if necessary, as well as a salvage UCL reconstruction with a docking technique after a failed primary suture-augmented UCL repair. In 7 fresh-frozen cadaveric upper extremities (mean age, 66.3 years), a custom shoulder testing system was used to simulate the late cocking phase of throwing. The elbow valgus opening angle was evaluated using a MicroScribe 3DLX device for sequentially increasing valgus torque (from 0.75 to 7.5 Nm in 0.75-Nm increments) at 90° of flexion. Valgus angular stiffness (in newton-meters per degree) was defined as the correlation of sequentially increasing valgus torque with the valgus opening angle through simple linear regression (slope of valgus torque - valgus opening angle curve). Four conditions were tested: intact elbow, distal UCL avulsion, primary UCL repair with double-strand suture augmentation using small-diameter bone tunnels, and subsequent docking UCL reconstruction in the same specimen. Load-to-failure tests were performed for primary UCL repair with double-strand suture augmentation and subsequent docking UCL reconstruction. With increasing elbow valgus torque, the valgus opening angle increased linearly in each condition (R2 ≥ 0.98, P < .001). Distal UCL avulsion resulted in significantly decreased angular stiffness compared with the intact UCL (P < .001). Both UCL repair with double-strand suture augmentation and subsequent UCL reconstruction showed significantly increased angular stiffness values compared with distal UCL avulsion (P < .001 and P < .001, respectively). On load-to-failure testing, there was no significant difference in stiffness, yield torque, and ultimate torque between the primary suture-augmented UCL repair and the subsequent UCL reconstruction (P = .11, P = .77, and P = .38, respectively). In all specimens undergoing the small-diameter ulnar bone tunnel technique for double-strand suture-augmented UCL repair, failure occurred by retear of the repaired ligament without causing an ulnar bone bridge fracture. Primary UCL repair with double-strand suture augmentation using small-diameter bone tunnels was able to restore valgus stability. When failure occurs, this technique retains enough cortical bone to permit subsequent docking UCL reconstruction.

Evaluating the bone-regenerative role of the decellularized porcine bone xenograft in a canine extraction socket model.

ObjectiveTo evaluate the efficacy of a novel decellularized porcine bone xenograft, produced by supercritical carbon dioxide extraction technology, on alveolar socket healing after tooth extraction compared to a commercially available deproteinized bovine bone (Bio‐Oss®).Materials and methodsNine dogs (about 18 months old and weighing between 20 kg and 30 kg) underwent extractions of lower second to fourth premolars, bilaterally. The dogs were randomly selected and allocated to the following groups: Group 1: control unfilled socket; Group 2: socket filled with decellularized porcine bone xenograft (ABCcolla®) and covered by a commercially available porcine collagen membrane (Bio‐Gide®); Group 3: socket filled with Bio‐Oss® and covered by Bio‐Gide® membrane. One dogs from each group was sacrificed at 4‐, 12‐, and 24‐week to evaluate the socket healing after tooth extraction. The mandible bone blocks were processed without decalcification and specimens were embedded in methyl methacrylate and subjected to histopathology analyses to evaluate the bone regeneration in the extraction sockets.ResultsAt 24‐week after socket healing, ABCcolla® treated defects demonstrated significantly higher histopathology score in new bone formation and bone bridging, but significantly lower score in fluorescent labeling than those of the Bio‐Oss®. In the microphotographic examination, decellularized porcine bone xenograft showed similar characteristics of new bone formation to that of Bio‐Oss®. However, there was significantly less remnant implant materials in the decellularized porcine bone xenograft compared to the Bio‐Oss® group at 24‐week. Thus, the decellularized porcine bone graft seems to have promising bone regeneration properties similar to that of Bio‐Oss® with less remnant grafted material in a canine tooth extraction socket model.ConclusionsWithin the limits of the study, we concluded that ABCcolla® treated defects demonstrated significantly more new bone formation and better bone bridging, but less amount of fluorescent labeling than those of the Bio‐Oss® group. However, clinical studies in humans are recommended to confirm these findings.

The midterm outcomes of ankle Dias-Tachdjian pronation-eversion external rotation physeal fracture in children treated by open reduction internal fixation with one-stage medial-lateral combined incision.

The objective of this study was to report the midterm outcomes and complications of ankle Dias-Tachdjian pronation-eversion external rotation (PEER) physeal fracture in children treated by ORIF with combined medial and lateral incision. A total of 21 children with ankle Dias-Tachdjian PEER physeal fracture underwent open reduction internal fixation treatment with combined medial and lateral incision between January 2015 and October 2017. The lateral distal tibia angle (LDTA) was measured to evaluate angular deformity and the X-rays were taken to evaluate the premature physeal arrest. All patients were followed up for an average time of 20.1 months (ranging from 17 to 25 months). Bone healing was achieved in all cases. American Orthopedic Foot and Ankle Society-Ankle and Hindfoot (AOFAS-AH) score of the patients improved from median 31 (11, 38) preoperation to median 68 (63, 73) postoperation to median score 91 (87, 96) at last follow-up. LDTA of the patients improved from 70.5 ± 4.9 preoperation to 90.0 ± 1.2 postoperation, to measure 90.6 ± 3.7 at last follow-up. The differences were statistically significant (P < 0.05). There is no premature physeal closure, ankle deformity in 19 cases. They could normally exercise and take part in normal sport activities. The remaining two cases had physeal bone bridge and premature physeal closure but could still carry on daily activities and thus were categorized as good. ORIF with one-stage medial-lateral combined incision for ankle Dias-Tachdjian PEER physeal fracture can decrease the rate of premature physeal closure and should be a treatment choice.

How Can We Differentiate Local Recurrence From Heterotopic Ossification After Resection and Implantation of an Oncologic Knee Prosthesis in Patients with a Bone Sarcoma?

Heterotopic ossification (HO) is common after total joint arthroplasty and usually does not cause diagnostic problems. However, the occurrence of HO after oncologic prostheses implantation can be troublesome as it may mimic a locally recurrent tumor. Because this distinction could have a profound impact on the surgeon and patient, it is important to distinguish the two entities; to our knowledge, no study has evaluated this after oncologic endoprosthetic reconstruction around the knee after tumor resection. (1) How common is the occurrence of HO compared with local recurrence (LR) after resection of bone sarcoma and the use of an oncologic knee prosthesis? (2) Are there any factors associated with the development of HO after limb salvage procedures with an endoprosthesis? (3) What features allow the surgeon to differentiate HO from a locally recurrent tumor in this setting? Between 2002 and 2018, we performed 409 resections of primary bone tumors followed by reconstructions with oncologic endoprostheses. Of these, 17% (71 of 409) died before 2 years and did not have HO at that time, 2% (8 of 409) were lost to follow-up before 2 years, and another 2% (10 of 409) did not have radiographs available at a minimum of 2 years after surgery (and had not developed HO before then), and so could not be analyzed, leaving 320 patients for analysis in this retrospective study. Forty-two patients were excluded; 2% (5 of 320) for a history of failed allograft reconstruction, 3% (8 of 320) for pathologic fracture at presentation, 2% (6 of 320) for inadequate or complicated biopsy, 1% (2 of 320) for stem fractures, 2% (7 of 320) for stem loosening, and 4% (14 of 320) for extracortical bone bridging, leaving 278 patients for final evaluation. Two observers analyzed AP and lateral radiographs for signs of HO at a mean follow-up of 63 ± 33 months after surgery. We defined HO as extraskeletal bone formation in soft tissues. The primary study endpoint was survivorship free from HO, as ascertained by a competing-risks estimator. To identify factors associated with HO appearance, the demographic, radiographic, clinical, pathologic, and surgical characteristics were compared between patients with HO and those who had no lesion. Characteristic features were also compared between patients with HO and those with LR to help their differentiation. Univariate analysis was used for all statistical evaluations. HO developed in 8% (21 of 278) of patients in whom oncologic knee prosthesis was implanted. LR developed in 10% (28 of 278) of the patients. According to survivorship estimates, the HO-free survival rate was not different from the LR-free survival rate at 2 years after oncologic knee reconstruction (76 ± 5% [95% CI 63 to 87] versus 74 ± 5% [95% CI 62 to 88]; p = 0.19). History of infection was more common in patients with HO than in patients with no lesion (19% [4 of 21] versus 5% [12 of 229], Odds ratio [OR] 6 [95% CI 2 to 17]; p < 0.001). The male sex was more common in the HO group as well (76% [16 of 21] versus 55% [128 of 229], OR 2 [95% CI 1 to 5]; p = 0.03). The Modular Universal Tumor and Revision System prosthesis was more frequently used in patients with HO (67% [14 of 21]) compared to those with no lesions (40% [92 of 229]; OR 2 [95% CI 1 to 5]; p = 0.02). The lesion border in radiographs was ill-defined in 19% (4 of 21) of patients with HO and 100% (28 of 28) of patients with LR (OR 8 [95% CI 3 to 20]; p < 0.001). The median time to the appearance of HO was shorter than the time to LR (8 months [3 to 13] versus 16 months [11 to 21], [95% CI 10 to 13]; p < 0.001). Pain at presentation was more frequent in patients with LR than in those with HO (86% [24 of 28] versus 14% [3 of 21], OR 36 [95% CI 7 to 181]; p < 0.001). HO may occur after the use of oncologic knee prostheses for reconstruction after tumor resection. In most patients, HO could be differentiated from local recurrence through identifying a well-defined border on radiographs. Otherwise, factors such as an earlier time of presentation and absence of pain could suggest an HO, rather than an LR. Level III, therapeutic study.

Implant-Free, Transtibial, Bone Bridge Fixation for Knee Surgery Including Tibial Spine and Meniscal Root Fixation

Fixation over bone bridge is commonly performed during transosseous pullout knee surgeries. This technique requires the drilling of 2 bony tunnels separately. Herein, we describe our technique in which bone bridge fixation is performed with a single bony tunnel. Our technique is described in 4 simple steps. Step 1: A short accessory tunnel is created from a point at least 1 cm away from the aperture of primary bone tunnel and opening into the lumen of the primary tunnel. Step 2: A shuttle suture (PROLENE) loop is passed from the accessory tunnel to the primary tunnel, and the loop is retrieved out of the primary tunnel using an 18-G epidural needle and arthroscopy probe. Step 3: Complimentary limbs of the pullout suture is then shuttled through the accessory tunnel using shuttle suture loop. Step 4: The knots are tied over the intervening bone bridge. Since the sutures are tied over the bone bridge, it has to be strong enough to provide support. This method of fixation is contraindicated when there is severe osteoporosis or if the tunnels are located in metaphysis. A supplemental video demonstration of the technique is included with this article.

Autologous cartilage and fibrin sealant may be superior to conventional fat grafting in preventing physeal bone bridge formation - a pilot study in porcines.

PurposeThe article compares physeal recovery after insertion of autologous cartilage and a conventional fat graft in a standardized porcine physeal gap model. Presence of a bone bridge was the primary outcome.MethodsTen porcines in two groups of five were included in a paired design. A standardized physeal gap in the distal femur was made in all animals. One group (n = 5) was randomized for deposition of autologous cartilage and a Tisseel® or Tisseel® alone. The autologous cartilage was harvested from the femoral articular surface. The other group was randomized for fat grafting or no grafts at all. All animals were housed for 14 weeks. Magnetic resonance imaging (MRI) was performed at 14 weeks prior to euthanasia. The physis was harvested for histology.ResultsMRI – Three bone bridges were seen in the fat grafted gaps. All empty gaps formed a bone bridge. No gaps filled with autologous cartilage and Tisseel® resulted in bone bridges. One gap filled with Tisseel® only caused a bone bridge. Histology – The cartilage grafted gaps recovered with physeal-like cartilaginous tissue in histological analysis.ConclusionsFat grafts seems ineffective in preventing bone bridges. The use of autologous cartilage may be superior to the current treatment. However, donor site complications were not investigated. The study serves as a proof of concept study and requires further investigation.Level of evidenceIII